Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brigadier General Wendell H Gilbert Tn State Veter during CMS and state inspections, most recent first.
Two cognitively impaired residents were left unsupervised, resulting in one resident entering another's room and engaging in inappropriate sexual contact. The incident was witnessed by a CNA, who left to find an LPN rather than immediately intervening, leading to a delay in separating the residents. Both residents had significant cognitive deficits, and the facility's policy required prevention of such abuse, but the residents were not adequately protected.
Failure to Prevent Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The facility failed to protect two residents from sexual abuse, as required by its own policy and federal regulations. The incident involved a resident with severe cognitive impairment, including traumatic brain injury and paranoid schizophrenia, who entered the room of another resident with moderate cognitive impairment and dementia. The first resident was found in bed with the second resident, both unclothed from the waist down, engaging in inappropriate sexual contact. The event was witnessed by a CNA, who left the room to find a nurse, and the nurse subsequently intervened to separate the residents. Medical record reviews indicated that both residents had significant cognitive deficits, with one unable to complete a mental status interview and the other displaying moderate impairment and short-term memory loss. The facility's policy outlined the need to prevent all forms of abuse, including sexual abuse, and to identify residents at increased risk, such as those with confusion or behavioral disturbances. Despite these policies, the residents were left unsupervised, and the incident was not immediately interrupted when first discovered by staff. Camera footage confirmed that the residents remained together and unattended for a period after the inappropriate interaction was witnessed. Interviews with staff revealed that there was no prior history of sexual aggression for either resident, and that staff were aware of the cognitive and behavioral challenges faced by both individuals. The CNA who discovered the incident did not immediately separate the residents but instead left to find a nurse, resulting in a delay. The nurse who responded found both residents unclothed and intervened to remove the first resident from the room. The incident was reported to law enforcement and Adult Protective Services, and both residents were subsequently monitored in separate locations.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Clarksville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ahava Healthcare Of Clarksville | 7.6 mi | ★★★★★ | 7 | 0 |
| Park Meadows Post Acute | 8.4 mi | ★★★★★ | 0 | 0 |
| Spring Meadows Health And Rehabilitation | 9.7 mi | ★★★★★ | 0 | 0 |
| Signature Healthcare Of Clarksville | 12.1 mi | ★★★★★ | 0 | 0 |
| Christian Heights Nursing And Rehabilitation Cente | 14.2 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.